Hospital Database NURS 212

Instructions: Use blue ink for day before clinical & red Ink for the clinical day. Get all of this information on the day before clinical, then update it on the day of care.

PATIENT PROFILEADMISSION INFORMATION Student Name: DC Collins 1.) Date of Care: 01-27-10

2.) Patient Initials: LS

3.) Age: 57(facesheet)

3.) Growth and Development Middle Adulthood – Gen.vs. Stagnation

4.) Sex:M (face sheet)

5.) Admission Date:01-21-10(face sheet)

6.) Reason for Hospitalization (face sheet): l. large hemothorax - syncope 7.) Medical Diagnosis: (Present diagnoses, past

diagnoses; physician’s History and Physical notes in chart; nursing intake assessment and Kardex) Past: Hypertension, Hypercholesterolemia, Depression, seizure disorder, alcoholism (pt. states two years dry) Recent: Cracked ribs mid-December

8.) Surgical Procedures: Date 01-26-10L. sided video-assisted thoracoscopic evacuation of hemothorax and potential decortication (surg. report not yet available)

Surgical Pathophysiology: Video thoracoscopy is performed in the operating room under general anesthesia. Patients have basic anesthetic monitoring including arterial pressure, electrocardiogram, continuous transcutaneous oxymetry, and end-tidal carbon dioxide tension. To ensure maximal exposure, a double-lumen endotracheal tube is used. After intubation, patients are placed in the appropriate lateral decubitus position. Videothoracoscopic procedures are performed with trocars or ports and usually require three 1- to 2-cm intercostal incisions. When possible, the sites of previously placed chest tube thoracostomies are used.

Paraphrased from http://ats.ctsnetjournals.org/cgi/content/full/63/2/327

Primary Medical Dx: left side hydropneumothorax

Pathophysiology (detail on the cause of the primary medical diagnosis): Hydropneumothorax = both Air and Pleural EffusionPneumothorax: These occur as a result of trauma or pre-existing pulmonary disease (eg TB, malignancy, emphysema, histiocytosis X, interstitial fibrosis). Trauma can allow gas into the pleural space via penetration of the visceral pleura, chest wall, diaphragm, mediastinum or esophagus. Iatrogenic pneumothorax as a result of CVP lines, thoracentesis or mechanical ventilation is not uncommon. However, widespread emphysema is the most common cause of secondary pneumothorax. Other causes of pneumothorax such as asthma, certain interstitial lung diseases, lung carcinoma or abscess are less common. An uncommon cause of pneumothorax is from the accumulation of gas produced by microorganisms in an empyema.Pleural Effusion: Systemic arterial vessels supply both pleural surfaces. Lymphatic vessels from the parietal pleura drain to lymph nodes along the anterior and posterior chest wall, whereas lymphatics from the visceral surface drain to the mediastinal lymph nodes. The pleural space normally contains 0.1-0.2 mL/kg of a colorless alkaline fluid, which has less than 1.5 g/dL of protein. The venous side drains approximately 90% of accumulated fluid in the pleural space, whereas lymphatics absorb the other 10%. Chest-wall and diaphragmatic movements enhance absorption of pleural fluid by the vascular and lymphatic vessels. Excessive filtration of fluid can overwhelm these efficient absorptive mechanisms and lead to the formation of pleural effusion.

All signs and symptoms – Highlight those your patient exhibits: Chest pain (from surgery), shortness of breath, tachycardia, tachypnea, cough (mild productive), fatigue, cyanosis, anxiety, restlessness, decreased or absent breath sounds, tracheal shift, mediastinal shift, unequal chest rise, hypotension, pale cool clammy skin, narrowing pulse pressure, hypoxia, hypercapnia, respiratory

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acidosis, loss of consciousness

9.) ADVANCE DIRECTIVES (NURSE’S ADMISSION ASSESSMENTS):

Living Will: N Power of Attorney: N Do not resuscitate (DNR) order (Kardex): N

10.) LABORATORY DATA: Reason why it pertains to patient. Indicate with an “L” if low or “H” if high.

Test NormsOn Admission

Current ValueDate

Test NormsOn Admission

Current ValueDate

Glucose 65-99 125H 141H 177H Albumin 3.5-5.0 2.8L 2.8L 2.1L

RBC 4.3-5.7 3.26L 3.55L 3.6L Hgb13.7-16.7

12.7L 11.9L 12.0L

HCT 40-50 36L 35L 35L EOS 0-7 4 12H 2L

EOS ABS 0.0-0.5 0.3 0.8H 0.2LBUN/Creatinine Ratio

7-24 11 39H

11.) DIAGNOSTIC TESTS

Chest X-ray: 1/22 0951: ↑ l. pleural effusion & heart size at upper limits of norm

Chest X-ray: 1/22 1523: Bedside AP CXR – Chest Tube PlacementNew l. thoracostomy tube placed. l. pleural eff. Slightly ↓ tho still moderate. l. lung aeration also improved, w/persistent l. basal consolidation. May be a tiny l. apical pneumothorax.

XR: 1/22 1912: r. tib/fib for r. leg pain. AP & cross table. Mild diffuse osteopenia. Mild patellofemoral osteoarthropathy.

CXR: 1/23/10 0910: Stable position of . thoracotomy tube. Redemonstration of mod. Airspace disease at l.l.lobe. Mod size pleural eff, tho slightly ↓ from last exam. No pneumothorax identified. Heart size normal.

Chest CT: 1/23/10 1741: Chest CT w/contrast. Follow-up post chest tube placement. Tube in proper position. l.l.lobe atelectasis & small l. sided pleural eff. w/ a displaced l. 9th rib fracture. Minimal atelectasis in r. lung base.

CXR: 1/24/10 0834: Tube in proper place. Persistent opacity l. inferior half of chest obscuring l. hemidiaphragm consistent w/ pleural disease. No pneumothorax. Heart not enlarged.

CXR: 1/25/10 0754: Tube in proper place. Interval drainage of l. pleural eff. Poor compliance of underlying lung – hydropneumothorax at l.lung base, but no increase in atelectasis. Stable patchy mild consolidation at r. lung base. Mild cardiomegaly. No evidence of l. ventricular failure.

Chest CT: 1/25/10 0931: w/o contrast. Tube in proper place. Residual l. pneumothorax 26mm, slightly larger laterally, slightly smaller anteriorly. Atelectasis appears unchanged in size. Small r. pleural eff still present. Mediastinal lymph nodes present, largest medial to main pulm. artery. Displaced l. 9th & 10th rib fractures identified.

CXR: 1/26/10 0755: Portable AP Chest tube stable. No interval change to l. basilar opacity. No pneumothorax.

CXR: 1/26/10 1028: Tube has been repositioned. Interval decrease in l. pleural eff. No pneumothorax identified. Cardiomegaly unchanged. Diffuse bilat. Interstitial and airspace opacities noted, consistent w/pulm. edema.

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13.) ALLERGIES/PAIN

13.) Allergies NKDA (medication administration

records):

14.) When was the last pain medication given? PCA Dilaudid q8min prn. Actively used.D/C’d PCA Mid Shift Percocet 1300

14.) Where is the pain?l.l. chest (Nurses’ notes) U.R. Leg

14.) How much pain is the patient in on a scale from 0-10?8/10 (Nurses’ notes, flow sheet) 0/10 chest, 8/10 U.R. Leg, 10/10 if standing/walking

15.) TREATMENTS

15.) Treatments (Kardex): l. chest tube What are the treatments for? Relieve hydropneumothorax Nicotine Replacement Patch Relieve smoking withdrawal Turn cough deep breathe Pneumonia prophylaxis Retention Catheter to gravity Prevent urine retention Chest tube at neg. 20 cm wall suction Drain hydropneumothorax Suction D/Cd Incentive Spirometer qh when awake Prevent pneumonia, exercise lungs HoB @ 60 deg. at all times Ease of breathing16.) Support services (Kardex): --- 17.) Consultations (Kardex): PT eval and treat as appropriate OT eval and treat as appropriate

18.) DIET/FLUIDS

Type of Diet (Kardex): Restrictions (Kardex):       Gag reflex intact      NPO Day of Surgery (1/26) until fully awake, then clear liquids remaining day of surgery. Post-op day 1 advance diet as tolerated to Cardiac Low Fat/Cholesterol/SaltAppetite:      Good      Fair      Poor X Breakfast %100 of liquid Lunch% 25 Supper%------ Started on clr liq, advanced as above for lunch

What types of foods are included in this diet and what foods should be avoided? See AboveLow fat, cholesterol, salt foods allowed

Fluid Intake: (Oral & IV) NPO day shift - 24 hours 600 mL

Check Those Programs That Apply:

Problems: Swallowing     , Chewing     , Dentures      (Nurses’ Notes)

Needs assistance with feeding      (Nurses’ Notes)

Nausea or Vomiting      (Nurses’ Notes)

Overhydrated or dehydrated      (evaluate total intake and output on flow

sheet)

Belching:      Other:      

Tube Feedings:     Type and Rate      (Kardex) 300 ml postop (arrived from PACU 1310) thru day shift

Is the patient’s intake greater than output? No • Calculate: -300

19.) INTRAVENOUS FLUIDS (IV Therapy Record)

Type and Rate: D5W 10 ml/HrD5W 10 ml/hr – D/C’d mid shift

IV dressing dry: edema:       redness: Not ObservedLFA near wrist. Dry, no edema or redness.

Other:LFA, mid forearm, saline lock. dry, no edema or redness

20.) ELIMINATION

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Last Bowel Movement: 01/24 24-hour Urine Output: See #18 above Foley/Condom catheter: Yes01/24 600 Urine + 550 CT drainage = 750 No

Check Those Problems that Apply:

Bowel: constipation X diarrhea      flatus      incontinence      belching     

Urinary:      hesitancy      frequency      burning      incontinence      odor     Other:      

21.) ACTIVITY (Kardex, flow sheet)

Ability to walk (gait): Not ob-served but is post op Antalgic, but well balanced, strong

Type of activity orders: Amb. TID post op day 1 & OOB to chair for all meals. Same

Use of assistive devices: cane, walker, crutches, prosthesis: NoneNone

Falls-risk assessment rating: Hendrich II, Score = 4 – High Risk1, Low Risk

No. of side rails required (flow sheet): None ordered 0

Restraints (flow sheet): None None

Weakness: No post op assessmentNone by end of shift

Trouble sleeping (Nurses’ Notes):Post op, unknownNone

PHYSICAL ASSESSMENT DATA

22.) BP (flow sheet): 22.) TPR (flow sheet): 23.) Height: Weight: 119/90 37.6/63/18 175.3 cm 90.2 kg 97/68 96.3/78/20 --- ---

REVIEW OF SYSTEMS(Check Nurses’ Notes and shift assessments for the latest information you can get.)

24.) NEUROLOGCIAL STATUS:      

LOC: alert and oriented to person, place, time (A&O x 3), confused, etc.: A&O x3, drowsy post opA&O x3 – drowsy until mid shift when PCA D/C’d

Speech: Clear, Appropriate Clear, Appropriate

Sensation: 4 extremities Intact x4Intact x3 Loss of sensation to touch in upper right leg after standing or walking for a couple of minutes

Pupils: PERRLAIntact PERRLA – 3 mm

Sensory deficits for vision/hearing/taste/smell:---NoneNone

25.) MUSCULOSKELETAL SYSTEM:

Bones, joints, muscles (fractures, contractures, arthritis, spinal curvatures, etc.): Fracture l. ribs 9&10, dx of r. leg mild diffuse osteopenia, mild patellofemoral osteoarthropathySevere pain (10/10), burning, and numbness in upper right leg upon standing or walking for more than a couple of minutes.

Muscle Strength: Grips equalStrength 3/5 and equal x3

Motor: ROM x 4 extremities      5/5 x4 5/5 x4

Casts, splint, collar, brace, Walker, W/C, CPM None None

26.) CARDIOVASCULAR SYSTEM:

Pulses (apical, radial, pedal) (to touch or with doppler): Pulses present bilat. radial & dorsalisPresent and strong, apical, radial, and dorsalis

Capillary refill (<3s): ---<3

Edema, pitting vs. nonpitting: 0 (upper/lower) 0No edema

Jugular neck vein (distention): NoNone

Heart Sounds: S1, S2, regular, irregular:     (rate, rhythm, strength) murmur, S3, S4 S1 S2S1, S2, No extra sounds

Any chest pain:Yes, 8/10 – r/t surgery7/10 before Percocet, 1 afterDiaphoresis: No NoNausea: No No

TED hose/plexi-pulses/compression devices: type: None None Other: --- No

27.) RESPIRATORY SYSTEM:

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Depth, rate, rhythm: Depth Reg, Rate 20Depth regular, Rate 20

Use of accessory muscles: ---No

Cyanosis:No No

Sputum: color, amount:--- None observed

Cough: productive, nonproductive:--- Mildly productive

Breath sounds: Dim bilat. basesA few rales left sideDim bilat. Bases,rales bilat bases

Use of oxygen / Flow Rate: *1310 arrived from PACU on 4L NC. *1440 Sats in 70’s – put on mask & ↑ O2 to 6L.*1450 Sats still ↓ing, incr. O2 to 9L – Sat ↑ to 92%96% on 6L maskstart of shift. ↓ to 85% off mask mid shift, ↑ 92% using Inc.Spirom., back to 88% off Inc.Spirom. Weaned to 4L late in shift. Off O2 by end of shift.

Oxygen humidification: ---Yes

Pulse oximeter: % oxygen saturation92%92%

Smoking: 40+ pack years – still smokes---

28.) GASTROINTESTINAL SYSTEM:

Abdominal pain, tenderness, guarding; distention, soft, firm: Not observed – pre op pt stated no pain.None

Bowel sounds x 4 quadrants:+ on AuscHypoactive after liquid breakfast, absent 1 hr later

NG tube: describe drainage:--- None

Ostomy: describe stoma site and stools: ---None

Other:---None

29.) SKIN AND WOUNDS:

Color, turgor, Temp:WNL Color / temp approp. With No tenting

Rash, bruises:---None

Describe wounds (size, location): Chest Tubes left side X2 – Not ObservedCT x2 l. side

Edges approximated: Not Observed---

Type of wound drains:---None

Characteristics of drainage: ---CT Drainage thin, red, non-purulent

Dressings (clean, dry, intact): IntactCT dressings clean, dry, intact

Sutures, staples, steri-strips, other: ---

---

Risk for decubitus ulcer assessment rating: Braden 19/23 20/23

Other: --- ---

30.) EYES, EARS, NOSE, THROAT (EENT):

Eyes: redness, drainage, edema, ptosis ---No redness, drainage, edema, ptosis

Ears: --- drainage:--- No drainage

Nose: redness, drainage edema ---No drainage or edema

Throat: sore:---Not sore

PSYCHOSOCIAL AND CULTURAL ASSESSMENT

31.) Religious preference --- (face sheet):

32.) Marital status S

33.) Healthcare benefits and insurance None (face sheet):

34.) Occupation None (face sheet): Long Haul Trucker

35.) Emotional state Calm and cooperative

Additional information to obtain from clinical units the night before clinical specific to your patient’s diagnosis:Standardized falls-risk assessment: Y

Pressure ulcerassessment:Y

Standardized skinassessment: Y

Standardized nursing care plans: Y

Clinical pathways:

Y

Patient education materials: YKnowledge deficits:--- Use of Inc. SpiromSelf care deficits:--- ---

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Other Assessment or Treatment Information not include above:      Doppler ordered for U.L. Leg – search for thrombi – none observed

New Medical Orders:      

D/C PCAD/C D5W along with the PCAD/C TeleWean from O2D/C Suction

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Concept Map Boxes, Nursing 212

Student: DC Collins Patient LS Room: 7A701 Date: 012710 1. Include all abnormal data from Database and only from the database. 2. Include all medications and treatments.3. Identify only problems focused on in Nursing 212. 4. Use only NANDA 2003-2004 diagnoses. Potential for problems cannot be in a box without an actual problem.5. Knowledge deficits for different areas should be written as separate problems.

Priority: 3 Problem: Acute Pain r/t fluid accumulation in the pleural space and chest trauma, and r/t tissue damage, 2º to surgical incision aeb verbalization of discomfort

Priority: 1 Problem: Ineffective Breathing Pattern r/t decreased lung expansion and alveolar collapse, 2º to air and fluid in the pleural space aeb dyspnea and difficulty maintaining appropriate O2 saturation

-Pain level 8/10 reported-Medication delivered via PCA-Chest Tubes-fractured L. 9th & 10th ribs

- Mild patellofemoral osteoarthropathy

-Cyclobenzaprine-Ketorolac-Hydromorphone-APAP/Oxycodone

-Dx of Pleural Effusion-Pain-Diminished breath sounds at bases-Mild rales left side-CXR / CT: hemothorax, pneumothorax, with alveolar collapse-Mild consolidation at bases-O2 in 70’s at 4L NC, Still ↓ at 6L by mask, and 92% on 9L by mask-Surgical Sedation-Order to TCDB-Order for Incent. Spirom.-HoB ordered to 60 deg at all times-Smoker 40+ pack years

-Guaifenesin-Albuterol

Priority: 4 Problem: Risk for Infection r/t surgical incision and ineffective protection, 2º to chest tube placement and VATS, and uncontrolled hemothorax, aeb blood labs and open pathways into the body

Reason For Hospitalization: Left Side Hydropneumothorax / VATS Evacuation of Hemothorax and potential decortication

Priority: 2 Problem: Ineffective Tissue Perfusion: Cardiopulmonary r/t excessive bleeding and decreased cardiac contractility aeb uncontrolled hemothorax and Dx of cardiomegaly

-High Eosinophil count-Low RBCs-Low Hct-High Eosinophils and Abs. Eosiniphils-Low Hgb

Key Assessments: (only highest priority) O2 SaturationBreathing PatternPainVitals

-Syncope was cause of ED admission-Glucose 141-Hct and RBCs Low, replaced by IV Saline-CXR and CT show Cardio-megaly

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-Foley-Chest Tubes-Temp of 37.6C

Wound sitesLOCChest Tube DressingMost recent K+ labs

-BP 119/90-Low Albumin

-Triamterene/HCTZ-Nitroglycerine-Atenolol

Connected boxes (if cannot draw connections) :

I don’t know:-Retention Catheter-Nicotine Replacement Patch-Mild diffuse osteopenia

-Ondansetron and Promethazine – Relieve N / V-Naloxone – Counter Opioids-Al.Hydroxide/Mg Hydroxide/Simethicone - Heartburn-Diphenhydramine - Itching-Bisacodyl - Constipation

1:      2:      3:      4:      

(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission

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Concept Map Step 4, 5, NURS 212

Student: DC Collins Patient: LS Room: 7A7-1 Date: 01-27-10Problem No. 1: Ineffective Breathing Pattern r/t decreased lung expansion and alveolar collapse, 2º to air and fluid in the pleural space aeb dyspnea and difficulty maintaining appropriate O2 saturation General Goal: Effective Breathing Pattern Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)1. The patient will exhibit self care AEB demonstrating pursed-lip breathing and using the incentive spirometer hourly on the day of care.2. The patient will demonstrate the ability to breathe comfortably AEB absence of labored breathing and O2 saturation above 92% on the day of care.Nursing Interventions Include each type: (A) assessment, (T) treatment, (E) education, (D) dependent, (I) independent, (C) collaboration, (EOC) assess EOCs; Include frequencies for each. List medication names.

Type of inter-vention(A, T, E, D, I, C, EOC)

Dele-gate(Y/N)

Patient Responses (Evaluation)

1. Demonstrate pursed-lip breathing and explain benefits

T,E,I Y Patient said he understood, and tried it several times.

2. Demonstrate use of Incentive Spirometer (IC) and explain benefits

T,E,I Y Had an IC on table, but said nobody told him what it was for. He demonstrated use.

3. Assess patient understanding of pursed-lip breathing and incentive spirometer, and probable level of compliance

I, A,EOC N After education, patient demonstrated both proficiently with practice.

4. Assess respiratory function, including lung sounds, for labored breathing, and O2 sats continuously if in distress; qH when O2 Sat is above 92%

I,A,EOC N No labored breathing. Dim. sounds & rales bilat bases. 92% avg on O2, mid 80’s off mask most of shift.

5. Assess Chest Tube for movement, and for proper drainage, proper suction, appropriate bubbling in chamber

I,A N CT remained in place, suction D/C’d, drainage continued

6. Titrate O2 as ordered to increase O2 saturation above 92%

T,D N *9L by mask beg. of shift 92%.*6L by mask early in shift 93%*Off O2 for bathing, 85% - IC use brought back up to 92%*4L by mask late in shift 92%*Off O2 by end of shift, low 90’s.

Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: With education, he learned that he could feel better and have more energy with proper breathing techniques and IC use. Was able to be off O2 long enough to bathe and ambulate by mid shift, and stay off O2, including after ambulation, by end of shift.(Note: this opportunity to see how important patient education is was as useful to me as it was to him)

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Problem No. 2: Ineffective Tissue Perfusion: Cardiopulmonary r/t excessive bleeding and decreased cardiac contractility aeb uncontrolled hemothorax and Dx of cardiomegaly General Goal: Improved Tissue PerfusionBehavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)1. The patient will demonstrate adequate tissue perfusion AEB palpable peripheral pulses, warm and dry skin, adequate urinary output, absence of respiratory distress, and remaining A&Ox3 on the day of care.2. The patient will demonstrate knowledge of treatment regimen, including appropriate exercise and medications AEB verbalization of these on the day of care.Nursing Interventions Include each type: (A) assessment, (T) treatment, (E) education, (D) dependent, (I) independent, (C) collaboration, (EOC) assess EOCs;Include frequencies for each. List medication names.

Type of intervention(A, T, E, D, I, C, EOC)

Dele-gate(Y/N)

Patient Responses (Evaluation)

1. Assess pulses, cap refill, and neuro status q2H; more often if in moderate-severe distress

A,I,EOC N Pulses strong, cap refill <3Neuro status intact throughout shift.

2. Keep legs below level of the heart T,I Y Done throughout shift3. Monitor skin and I&O at least twice per shift A,I Y No cyanosis, I&O

remained in balance throughout shift

4. Assess patient knowledge about the implications of smoking, proper exercise on the day of care, and knowledge of medications and procedures being used for his treatment, before education.

A,I,EOC N Knows smoking issues. Didn’t know about IC use or that movement helps healing and to prevent clots. Did know about his current meds.

4. Educate patient about effects of smoking on cardiopulmonary system and offer resources on smoking cessation

E,I N Wasn’t interested.

5. Educate patient about exercises appropriate for the shift as well as medications and procedures

E,I N Had more energy and felt better after use of IC, and again after getting OOB to bathe.

Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: Perfusion remained good throughout shift with good pulses. Pt voided at least 3 times. Sats dropped to mid 80’s off O2 early in shift, but progressed to being off O2 in low 90’s by end of shift. Breath sounds still remained diminished in bilat bases, and rales were heard in both bases by end of shift, but as the day progressed and he used IC more often, he had more energy and spent more time OOB.

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Problem No. 3: Acute Pain r/t fluid accumulation in the pleural space and chest trauma, and r/t tissue damage, 2º to surgical incision aeb verbalization of discomfort General Goal: Reduce Pain Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)1. The patient will report pain intensity: 0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-9= severe pain, 10= worst pain imaginable, and set goal level at 3/10 or better, AEB verbalization of understanding of scale and goal rating on the day of care.2. The patient will report that pain management regimes relieve pain AEB report of pain maintained at 3/10 or less on the day of care.Nursing Interventions Include each type: (A) assessment, (T) treatment, (E) education, (D) dependent, (I) independent, (C) collaboration, (EOC) assess EOCs;Include frequencies for each. List medication names.

Type of inter-vention(A, T, E, D, I, C, EOC)

Dele-gate(Y/N)

Patient Responses (Evaluation)

1. Educate patient about pain rating system E, I N Pt. understood scale already

2. Instruct patient about importance of managing pain level, as it is easier to manage than to bring pain level back down

E, I N This was new to him, but he had already been on PCA and using it regularly when awake anyway.

3. Educate patient about non-pharmacological pain relief methods, including, positioning, slow deep breathing, muscle relaxation, etc.)

E, I N Expressed interest in breathing as a way to control pain. Stated it helped.

4. Have patient describe how unrelieved pain will be managed

E, I N Stated he would continue with slow, deep breathing, muscle relaxation, and repositioning himself.

5. Administer pain medication as ordered:PCA Dilauded 0.2 mg q8MPercocet once PCA D/C’d, once, mid shift. Shift ended before another dose due

T, D N (nar-cotics) Y for non

PCA, and later Percocet, reduced pain in chest to 1-2/10, though it didn’t touch the newly reported U.R. Leg pain

6. Assess pain level q2h and after meds administered

A, I, EOC N Pain remained low to non-existent for chest area (fractured ribs / chest tubes) as long as meds in effect, but nothing helped the leg pain.

Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: The goal was partially met. The known and expected pains in his chest due to fractured ribs, the presence of the chest tubes, and the hydropneumothorax were well controlled by medications, proper breathing, positioning, etc. But the newly reported leg pain remained uncontrolled across the shift. Recorded the pain levels and symptoms. Pt. also reported these to the physician, PT, and OT.

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Problem No. 4: Risk for Infection r/t surgical incision and ineffective protection, 2º to chest tube placement and VATS, and uncontrolled hemothorax General Goal: Absence of Infection Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)1. The patient will remain free from signs and symptoms of infection AEB by showing no undue redness, warmth, or discharge at the surgical or chest tube sites, and core temperature < 99C on the day of care.2. The patient will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care AEB verbalizing understanding of processes and willingness to perform such care on the day of care.Nursing Interventions Include each type: (A) assessment, (T) treatment, (E) education, (D) dependent, (I) independent, (C) collaboration, (EOC) assess EOCs;Include frequencies for each. List medication names.

Type of intervention(A, T, E, D, I, C, EOC)

Dele-gate(Y/N)

Patient Responses (Evaluation)

1. Assess wound sites, chest tube insertion points, skin, and core body temperature q2H

A,I,EOC N Could only assess dressings (not wounds), which remained clean, dry, intact. Temperature remained in the upper 96 deg. F range across shift.

2. Clean wounds and change dressings q2H and/or as allowed by orders

T,I Y Dressings remained in place across shift.

3. Assess lung sounds, sputum, pt. use of incentive spirometer, skin for moisture and breakdown.

A,I,EOC N Lung sounds did not worsen. No sputum observed. No diaphor-esis. No indication of skin breakdown and found to be low risk.

4. Assess pt. knowledge of and use of appropriate hygiene measures before and after instruction

A,I,EOC N Patient well understood hygiene and need to perform it well.

5. Instruct patient where knowledge is deficient E,I N Use of IC was only observed knowledge deficiency.

6. Have patient repeat back and demonstrate these measures.

E,I Y After instruction, he used the IC hourly

Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: Patient maintained a lack of S&S of infection across shift, reduced his risk of pneumonia by beginning use of IC, and demonstrated thorough knowledge of need for good hygiene to prevent infection. His eosinophil count dropped from 12 the previous day to 2 today.

(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission

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IV Medication Administration / Other Skills Form Nursing 212

student name DC Collins date 01/27/10

I. IV Medication Administration PreparationComplete and show form to instructor before administering the medication. After clearance from your instructor, all parenteral medications must be administered either with a staff RN or LPN or instructor.

Medication #1 Medication #2 Medication #3 Medication #4Drug name: generic and trade if known D5W Reglan

Metoclopramide

Is this order current?Date: Time:

Y01/26/101515

Y1/27/101300

Dose Safe? Y YCalculation correct? --- ---Why ordered? IV Maintenance ↑ Gastric

MotilityAllergy to this drug? N NPrimary IV site location:Patent?Date inserted:Type:Size: Length:Secondary IV site present?

Left ForearmYNotObserved

LFA prox to wristY1/21/10Primary

Y – SL distal to elbow

IV access typePeripheral?Central?PICC?Locked? IV fluid type:IV rate:

Peripheral

D5W10 mL / hr

Peripheral

D5W10 mL / hr

Side/Adverse effect #1, potential ↑ Serum Glucose DrowsinessSide/Adverse effect #2, potential Extrapyramid

al reactionsSide/Adverse effect #3, potential RestlessnessSide/Adverse effect #4 potentialSide/Adverse effect #5, potentialSide/Adverse effects, present, include dataShould pt. receive drug? Y NonePush Medication?Syringe size:Needle size:Filter needed?Administration Rate in minutes:

--- Yes3 mL------1-2

Syringe Pump / Piggyback Medication?Tubing expired?Tubing primed?Administration Rate in minutes:

---

NS Flush Needed?NS Amount:

---3 mL

13

NS Syringe size: 10 mLHeparin Flush needed?Heparin Flush Units:Heparin Flush Syringe size:

--- No

Give medication. Procedure Observed/Assisted by:

--- EG

14

MEDICATION RESEARCH, Nursing 212

Instructions: Complete this form for all medications on assigned patient including PRN, all IV solutions and additives. Bring a drug reference to clinical. For TPN, list each major component on a separate line, with additional data listed separately. Reactions may be transposed to cards or reused from a file.

Student: DC Collins Patient Name: LS Room: 7A7-01 Date: 01/27/09

ALLERGIES: REACTION(S): May reuse this information for subsequent patients by copying and pasting it in.

Medication name (trade/generic)Drug dose, route & frequency

Dosesafe?

Time due this shift

Expected effects on this patient

What should you check before giving this med on this patient?

What was the assessment right before and after the medication?

Major side effects(most common)

APAP/Oxycodone 325/5 mg tab1-2 tab PO Q4H PRN(Percocet)

Y PRN Pain relief Pain, type, loc, intensity

8/10 U.R. Leg8/10 U.L. Chest8/10 U.R. Leg1/10 ½ hr Chest

CNS: confusion, sedationGI: Constipation

Al. Hydroxide / Mg. Hydroxide / Simeth-icone Suspension30 ml PO Daily PRN

Y PRN Heartburn Existence of gastric pain

      Constipation

Albuterol SVN2.5 mg/3 ml solnQ4H

Y 09001300

Improve breathing

Lung sounds, pulse, BP

Dim bilat bases, rales bilat bases, before and after

CNS: Nervousness, restlessness, tremorCV: Chest pain, palpitations

Albuterol SVN2.5 mg/3 ml solnPRN

Y PRN Relieve SoB Lung sounds, pulse, BP

      CNS: Nervousness, restlessness, tremorCV: Chest pain, palpitations

Atenolol50 mg tab2 tabs PO Daily(Tenormin)

Y 0900 ManageHTN

BP, ECG, Pulse for baseline

BP checked q 2H

CNS: fatigue, weaknessGU: erectile dysfunction

Bisacodyl EC5 mg tab1 tab PO BID

Y 0900 TreatConstipation

Abd. Dist., bowel sounds

No dist., hypoactive

Abdominal cramps, Nausea

Cyclobenzaprine10 mg tab1 tab PO BID PRN

Y 0900 Relieve cramping Pain, muscle stiffness, ROM

      CNS: Dizziness, drowsinessEENT: dry mouth

Diphenhydramine50 mg/1 mL IV inj25 – 50 mg /0.5 – 1 ml IV Q$H PRN

Y PRN Relieve itching Itching       CNS: drowsinessGI: anorexia, dry mouth

Guaifenesin ER600 mg tab1 tab PO BID PRN

Y PRN Expectorant Lung sounds, freq and type of cough, type of secretions

      CNS: dizziness, headacheGI: N / V, diarrhea, stomach pain

15

Derm: Rash, urticariaTriamterene / HCTZ37.5/25 mg tab1 tab PO Daily

Y 0900 Prevent K+ loss / Antihyper-tensive

BPLatest K+ levelsPeripheral edema at least 1/day

K+ levels WNLNo edema

Hyperkalemia/Hypokalemia

Hydromorphone1 mg / 1 mL IV inj1-2 mg IV IntQ1H PRN

Y PRN Relieve pain BP, pulse, Resps, bowel function, pain type, loc, intensity, cough, lung sounds

CNS: confusion, sedationCV: hypotensionGI: constipation

Hydromorphone1 mg/1ml PCA inj 30 ml0.2-0.3 mg IV IntQ8M

Y PRN Relieve Pain BP, pulse, Resps, bowel function, pain type, loc, intensity, cough, lung sounds

Dim bilat bases, rales bilat bases, before and after

CNS: confusion, sedationCV: hypotensionGI: constipation

Ketorolac30 mg / 1mL inj15 mg, 0.5 mL IV Q6H

Y PRN Relieve Pain Pain type, loc, intensity

CNS: drowsinessMisc: anaphylaxis

Naloxone0.4 mg/ml inj0.1 mg, 0.25 mL IV PRNif RR =< 8

Y PRN Counter Opioid Resp rate, rhythm, depthPulse, ECG, BP, LOC

Hypersensitivity if opioid use > 1 week

Nicotine21 mg/24 hr patch1 patch/24 hours

Y PRN Prevent / ManageNicotineWithdrawal

HR, current patch site for reactions before replacing in new site

HR 78No reactions

CNS: Headache, insomniaCV: tachycardiaDerm: burning at patch site, erythema, pruritis

Nitroglycerin0.4 mg tab #25 btl0.4 mg, 1 eA, SublingualDaily – may repeat q5M x3 providing SBP over 90 and call physician

Y PRN Prophylaxis for angina pectoris / Adjunct treatment of CHF

BP, pulse, ECG CNS: dizziness, headacheCV: hypotension, tachycardia

Ondasteron4 mg/2mL inj4 mg/2mL IV Q8H PRN

Y PRN Relieve N / V

N / V, abd. Dist., bowel sounds

CNS: headacheGI: constipation, diarrhea

Promethazine 25 mg/1mL inj12.5-25 mg, 0.5 – 1mL IV Q4H

Y PRN Relieve N / V

BP, Pulse, RR Confusion, disorientation, sedation

Famotidine (Pepcid)20 mg / 10 mL10 mL IV daily

Y 0900 Relieve Heartburn

--- --- Confusion

Metoclopramide20 mg / 2 mL2 ml IV daily

Y 1300 Incr. gastric motility

N / V, abd. Dist, bowel sounds

No N / V, bowel sounds absent

Drowsiness, extrapyramidal reactions, restlessness

Heparin5000 U / 1 mL1 mL q8H

Y 1300 Thrombus prophylaxis

S&S of bleeding, bruising, hematuria, BP

BP WNL, no bruising, blood in CT drainage but not elsewhere

Anemia, thrombocytopenia

16

IV MaintenanceSolution Dextrose 5% in water500 mL IVContinuous

Y Cont                        

17

Medical Surgical Report (written or verbal), Nursing 212Student: DC Collins Date: 01-27-10Complete and communicate to the instructor before the end of shift.Patient: LS Room: 7A7 Patient Room

Diagnosis/Surgery:L. Hydropneumothorax

HD6

POD1

Diagnosis/Surgery: HD POD

Oncoming Report Summary:Age 57 male. Dr. Luber. L. CT x2 High temp evening shift. Tylenol brought it back down. 9L by mask overnight as O2 ↓ to mid 80s. Liq. diet through breakfast, adv. to normal diet as tol. No BM. Foley D/C’d. PCA 0.2 q8M

Oncoming Report Summary:

Assessment Summary:Neuro: A&O x3. Drowsiness ↓ after PCA D/C’dResp: 93% 4L mask. No dyspnea. RR 20 evenDim. Sounds / Rales bilat. basesCV: S1 S2 No extra sounds, pulses strong bilat radial / dorsalisGI: No BM since 1/24. BT hypo x4 after liq. bkfst, absent thereafter.GU: Voiding. 300 in 400 out.Skin: Clr/Tmp approp.Other: Act: up ad lib. Walks w/assistPain: 1/10 chest, 8/10 newly rep. URLeg pain w/burning sensation & numb to touch.

Assessment Summary:Neuro:Resp:CV:GI:GU:Skin:Other:

Medical Interventions:*Doppler ordered for leg pain. No thrombus observed*Wean off O2*D/C Tele*D/C PCA and D5W*D/C Suction

Medical Interventions:

MD Service, Assessment and Plan:Plan to discharge 1/29

MD Service, Assessment and Plan:

MD Service, Assessment and Plan: MD Service, Assessment and Plan:

Interdisciplinary Team Assessment and Plan:PT: arrived when pt amb. the quad. Encouraged more of same.

Interdisciplinary Team Assessment and Plan

18

Interdisciplinary Team Assessment and Plan:OT assured that stay with sister after discharge arranged. OT found pt capable of self care.

Interdisciplinary Team Assessment and Plan

Nursing Team Plan:Encourage movement and ambulation 2x shiftRemind to use IC and purse-lipped breathing.Observe for S&S of infectionObserve O2 q2h now that he is off O2.Monitor pain, burning, sensation in URLeg

Nursing Team Plan:

End of Shift Report:*M. Age 57. *In for Hydropneumo.*Hx of ETOH. *40+ pack years*Full Code *A&O x3 *CTubes x2 left side. Slow drainage*CV: HRR, good pulses*Pulm: Dim sounds & rales bilat bases. Last O2 92% on RA*GI/Diet: Regular *GU: Voiding*Skin: Color/Temp appropriate*Meds: Percocet, Albuterol, Famotidine, Reglan, Heparin, Atenolol, Bisacodyl, Triamterene/HCTZ, Nic Patch, ReglanMobility: Up ad lib, full ROM, rearranged his own furniture. Encourage longer amb around quad.Mood: Excellent, joking.*Pain: Controlled for chest 0-1/10. URLeg 8-10/10, + burning and numbness to touch, upon standing/walking for several minutes. Doppler found no thrombus. Awaiting further orders.

End of Shift Report:

19

Second and Third Patient Step 4, 5: Mini-Map, Nursing 212Complete this form for each second and third patient during the clinical day. Indicate the problem using the priority number from the concept map. Show to instructor during the day. Use the map boxes to quickly organize data.Student: DC Collins Patient: CF Room: ED Date: 02/03/2010General Expected Outcomes on the day of care: 1. The patient will report pain intensity: 0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-9= severe pain, 10= worst pain imaginable, and set goal level at 3/10 or better, aeb verbalization of understanding of scale and goal rating by end of first rounding after arrival.

ProblemPriority #’s

1

2. The patient will report that pain management regimes relieve pain AEB report of pain maintained at 3/10 or less by the end of shift.

1

3. The patient will exhibit reduced dizziness aeb report of reduced dizziness and steadier gait on day of care

2

4. The patient will remain free from injury aeb no falls or other movement related injury to self by end of shift

2

5. The patient will exhibit knowledge of symptoms of infection of which to be aware aeb verbalizing those symptoms, including increase / spread of pain, fever or chills, excessive sweating, nausea.

3

6. The patient will remain free from additional signs and symptoms of infection (other than abd. pain and dizziness) aeb core temp <99F, LOC intact, no diaphoresis, and no nausea by end of shift

3

General Nursing Interventions:1. Explain pain scale (as above) to patient and elicit verbal understanding of the scale from the patient upon admission to ED. (E, I – No delegation)

1

2. Assess pain level, type, and location immediately upon arrival and q30M (A, I, EOC – No delegation)

1

3. Provide pain medication as ordered, prn (T, D – No delegation (narcotic)) 14. Assess level of dizziness – more or less than upon admission – more or less upon laying down / sitting upright – more or less upon movement, immediately upon admission and q30M. (A, I, EOC) – No delegation)

2

5. Use two side rails to prevent accidental fall from bed, escort pt to bathroom or for any necessary ambulation (possibly with wheelchair) prn throughout shift. (T, I – can be delegated

2

6. Provide call light and verify patient’s understanding that she should inform us if she needs anything, to ensure compliance with bed rest, upon admission and with each rounding q30M – (T, I, can be delegated)

2

7. Start IV NS Wide Open as per standing order 38. Assess for S&S of infection (as above #5), core temp, and LOC upon arrival and q30M (A, I, EOC – no delegation)

3

9. Educate patient about symptoms (as above #5) immediately upon arrival 3

10. Assess labs as they become available and keep physician updated ASAPEOCs not met (indicate # from above): 1: Pain was reduced shortly after each admin of 2 mg Morphine to 5/10, but quickly raised back up to 7/10 (within 30 mins of report of 5/10)2: Pt was less dizzy when sitting upright than standing, laying down than sitting upright, and when HoB was 45 deg rather than flat. Dizziness reduced, but not eliminated3: No additional pain or S&S of infection *except* spread of lower R. abd. pain spread to lower R. abd.How will you modify plan? I wouldn’t. Keep pt hydrated, in bed as much as possible, assess

20

vitals, LOC and S&S of infection often.

Priority: 1 Problem: Acute Pain r/t undiagnosed lower back pain aeb pt report and guarding

Priority: 2 Problem: Impaired Physical Mobility with Risk for Injury r/t dizziness aeb pt report and impaired gait

-Pt reports pain 7/10 in R. lower back-Guarding of lower back and abdomen-Pain radiated to R. lower abd. during shift-Physician suspects possible appendicitis

-Morphine

-Wheelchair to bed-Pt states reduced dizziness when laying down, but still exists

-Zofran-Morphine

Priority: 3 Problem: Risk for Infection r/t lower back pain and dizziness

Reason for Hospitalization: Dizziness – Lower Back Pain

Priority:       Problem:      

-Physician reports suspicion of appendicitis

-Rocephin-NS Wide Open

Key Assessments: (only highest priority) -Vitals-Heart Rhythm-Orthostatic BP-Meds recently taken- Lungs / O2 Sat / Resps-Perfusion

I don’t know:                                    

(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission

21

EDName: DC Collins Date: 02/03/2010 Score:        /10Complete this form as your clinical day proceeds. Turn into your instructor at the end of the shift.Please fill the data for your day of clinical that you did or someone else did. For IVT, complete only the information that is available to the IVT team.Most Interesting Patient Sickest Patient Another patientRm Last name ED Rm Last name CF Rm Last name CBReason Here: 85 y.o. F sent by nursing home for vomiting x1

Reason Here: 59 y.o. F, Dizziness, R. lower back pain

Reason Here: 27 y.o. F, Syncope and SoB, 30 wks pregnant, c/o intermittent tightening stomach muscles

Labs:Stool, for C-diff, results not back

Abnormals and reason:UA 3+ Blood 2+ Leukocytes

Labs:Awaiting labs from Allenmore

Abnormals and reason:

Labs:UA

Abnormals and reason:UA – Urine hazyGlucose 118 HPot 3.4 LowTotal Protein 6.1 LAlbumin 3.2 LRBC 3.63 LHct 3.2 LSuspected Low Iron, inadequate nutrition, and not enough rest.

Other tests today:Abd. C/T – results not back

Other tests today:Abd. CT with contrast – awaiting results

Other tests today:Venous Doppler RLE LLE – no DVT seenAbd CT with contrast, awaiting results

Abnormal physical assessment and times:

Attempted straight cath and foley – third nurse successful on several attempts.

Severe rash, bright red, both buttocks, reaching up inner thighs and to mons pubis.

Severe diarrhea, very liquid, green and tarry, q5 minutes or less, and upon abd. contractions related to pain.

Stool draining out of Foley

Lung sounds: Clear bilat

Heart Sounds: S1, S2 no extra sounds

Abnormal physical assessment and times:

IV diff. to start. Former IVDA (more than 10 years ago.

BP 115/84 upon arrival. Dropped to mid80’s/mid 50’s after 2 mg Morphine – next dose held

BP 100/70 until 2 mg Morphine given, dropped to mid 80’s/mid 50’s again. Next dose held.

Repeat of the above once more.

D/C’d IV in R. FA after CT – Site swollen, red, warm, painful to touch

Pt less dizzy upon laying down, but still dizzy

Lung sounds: Clear bilat

Heart Sounds: S1, S2, no extra sounds

Abnormal physical assessment and times:

Pain in L. lower back radiated during stay to bilat.

HR: 116 initial assessment, 108 after Morphine

Lung sounds: Clear Bilat

Heart Sounds: S1, S2, no extra sounds

Comfort level: Comfort level: Abd. and lower back Comfort level: Pain 4/10,

22

Severe pain when rash touched, for cleaning after diarrhea or attempts to insert cath, for example. Could not state a number on a scale.

time med due:Imodium ASAP, once

pain 7/10 pre-Morphine, 5/10 30 mins later. Continuous pattern across shift.

time med due: IV Morphine inj 2 mg, q30M prnZofran - once

contractions pt believes are Braxton-Hicks.

Pain started in Lower R back, and spread to bilat lower back.

time med due:IV Morphine inj 2 mg, q 30 M x3 prnIV Rocephin inj 1gm, ASAP, once IV Zofran inj 8 mg, ASAP, once

EKG:N/A

EKG:Normal sinus rhythm

EKG:Normal sinus

Pulse ox O2Unable to take – hands too cold to register

pulse ox O295%, 94%, 96% on RA

pulse ox O2100, 100, 100, on RA

IV site: size solution rateR. Hand, 22Gauge, NS, Wide Open

IV site: size solution rateL. Hand, 22 Gauge, NS, Wide OpenR.FA, 20 Gauge, NS, Wide Open for CT, D/C’d after CT.

IV site: size solution rateR. hand, 20 Gauge, NS, Wide Open

Vs: T: 97.6, P: 84, RR: 24, BP: 109/67

Vs: T: 98.0, P: 55, RR: 24, BP: 96/45

Vs: T: 99.2, P: 116 (before Morphine, 108 30 mins later), RR: 20 (before Morphine, 16 30 mins later), BP: 109/75,

Drains: amount

None

Drains: amount

None

Drains: amount

None

I/O analysis:

Too soon for analysis – IV NS wide open after scant return from Foley

I/O analysis:

Too soon for analysis, also NPO

I/O analysis: ---

Physicians (service, time rounded, impressions and plan):

Suspect fistula between colon/rectum and urinary tract.

Physicians (service, time rounded, impressions and plan):

Suspect appendicitis

Physicians (service, time rounded, impressions and plan):

Probable UTI

Other medical team members (service, time rounded, impressions and plan):

N/A

Other medical team members (service, time rounded, impressions and plan):

N/A

Other medical team members (service, time rounded, impressions and plan):

OB: FHR 135, moderate variability, 10 Accels, Zero Decels, positive fetal movement, Acc 150 bpm x30 seconds, pt. denies bleeding or rupture, no signs of B-H contractions

Goals for the patient today /time needed

Reduce / stop diarrhea and vomiting

Improve Rash

Goals for the patient today

Reduce PainReduce effect of dizziness

Goals for the patient today

Reduce Syncope / Improve breathingReduce chance of PE

RN activities to achieve those goals

IV StartIV Rocephin

RN activities to achieve those goals

Encourage slow, deep breathingAdmin IV Morphine

RN activities to achieve those goals

Patient laying downReduce Anxiety

23

Collect stool sampleUrinary Cath and collect UA sampleSend for abd. CTKeep perineal area cleanProvide perineal moisture barrier

D/C infiltrated IVPt. positioningMaintain NPO status until diagnosisFall preventionMaintain hydrationHold Morphine when hypotensive

Suggest OB ConsultAssess LE edema / for Homan’s SignMaintain LE below heart levelMonitor Vitals q30M

Expected Time to DC/Transfer:Needs before DC/Transfer:

Unknown – diagnosis still to be established.

Expected Time to DC/Transfer: Needs before DC/Transfer:

Unknown – diagnosis still to be established.

Expected Time to DC/Transfer:Needs before DC/Transfer:

Unknown – no timeline established by physician

24